Effectiveness of interventions for improving social inclusion outcomes for people with disabilities in low‐ and middle‐income countries: A systematic review

Abstract Background People with disabilities—more than a billion people worldwide—are frequently excluded from social and political life, and often experience stigmatising attitudes and behaviours from people without disabilities. This stigma, coupled with inaccessible environments and systems and institutional barriers (e.g., lack of inclusive legislation), may result in discrimination against people with disabilities (and their families) to the degree that they are not able to enjoy their rights on an equal basis with others. Objectives This review examines the effectiveness of interventions for improving social inclusion outcomes (acquisition of skills for social inclusion, broad‐based social inclusion, and improved relationships) for people with disabilities in low‐ and middle‐income countries (LMICs). Search Methods We searched academic and online databases, carried out citation tracking of included studies, and contacted experts to ensure our search was as comprehensive as possible. We also ran the searches with search terms specific to social inclusion review using Open Alex in EPPI reviewer. Selection Criteria We included all studies which reported on impact evaluations of interventions to improve social inclusion outcomes for people with disabilities in LMIC. Data Collection and Analysis We used review management software EPPI Reviewer to screen the search results. Two review authors independently extracted the data from each study report, including for the confidence in study findings appraisal. Data and information were extracted regarding available characteristics of participants, intervention characteristics and control conditions, research design, sample size, risk of bias and outcomes, and results. Random‐effects inverse variance weighted meta‐analytic methods were used to synthesise standardised mean differences for the outcomes. Main Results We identified 37 experimental and quasi‐experimental studies. Studies were conducted in 16 countries, with the majority of the included studies (n = 13) from South Asia and nine each from East Asia, the Pacific, the Middle East, and North Africa. Most studies targeted children with disabilities (n = 23), and 12 targeted adults with disabilities. Most focused on people with intellectual disabilities (n = 20) and psychosocial disabilities (n = 13). Regarding intervention content, most (n = 17) of the included programmes aimed to improve the social and communication skills of people with disabilities through social skills training programmes. Ten studies aimed at providing personal assistance and support and evaluated the effects of a parent training programme on the interactive skills of parents of children and their children with disabilities. We calculated effect sizes from experimental and quasi‐experimental studies for outcomes on skills for social inclusion, relationships of people with disabilities with family and community members, and broad‐based social inclusion among people with disabilities. A meta‐analysis of 16 studies indicates an overall positive, statistically significant and large effect of the interventions for skills for social inclusion with standardised mean difference (SMD) = 0.87, confidence interval (CI) = 0.57 to 1.16, k = 26, I 2 = 77%, p < 0.001). For relationships across 12 studies, we find a positive but moderate effect (SMD = 0.61, CI = 0.41 to 0.80, k = 15, I 2 = 64%, p < 0.01). As for the overall effect on broad‐based social inclusion, we find the average effect size was large, and there was significant dispersion across studies (SMD = 0.72, CI = 0.33 to 1.11, k = 2, I 2 = 93%, p < 0.01). Despite the significant and large effects estimated by the studies, some limitations must be noted. Although there was a consensus on the direction of the effects, the studies presented considerable heterogeneity in the size of the effects. A majority (n = 27) of studies were assessed to be of low confidence related to methodological limitations, so the findings must be interpreted with caution. Tests for publication bias show that the effect sizes of social skills (p < 0.01) and social inclusion (p = 0.01) are all likely to be inflated by the existence of the publication bias. Authors’ Conclusions The review's findings suggest that various interventions to improve the social inclusion of people with disabilities have a significant positive effect. Interventions such as social and communication training and personal assistance led to significant improvement in the social behaviour and social skills of people with disabilities. Studies targeting broad‐based social inclusion showed a large and significant positive effect. A moderate effect was reported from interventions designed to improve relationships between people with disabilities and their families and communities. However, the findings of this review must be interpreted cautiously, given the low confidence in study methods, severe heterogeneity and significant publication bias. The available evidence focused primarily on individual‐level barriers such as interventions for improving social or communications skills of people with disabilities and not the systemic drivers of exclusions such as addressing societal barriers to inclusion, such as stigma reduction, and interventions to strengthen legislation, infrastructure, and institutions.

psychosocial disabilities (n = 13). Regarding intervention content, most (n = 17) of the included programmes aimed to improve the social and communication skills of people with disabilities through social skills training programmes. Ten studies aimed at providing personal assistance and support and evaluated the effects of a parent training programme on the interactive skills of parents of children and their children with disabilities. We calculated effect sizes from experimental and quasi-experimental studies for outcomes on skills for social inclusion, relationships of people with disabilities with family and community members, and broad-based social inclusion among people with disabilities. A meta-analysis of 16 studies indicates an overall positive, statistically significant and large effect of the interventions for skills for social inclusion with standardised mean difference (SMD) = 0.87, confidence interval (CI) = 0.57 to 1.16, k = 26, I 2 = 77%, p < 0.001). For relationships across 12 studies, we find a positive but moderate effect (SMD = 0.61, CI = 0.41 to 0.80, k = 15, I 2 = 64%, p < 0.01). As for the overall effect on broad-based social inclusion, we find the average effect size was large, and there was significant dispersion across studies (SMD = 0.72, CI = 0.33 to 1.11, k = 2, I 2 = 93%, p < 0.01). Despite the significant and large effects estimated by the studies, some limitations must be noted. Although there was a consensus on the direction of the effects, the studies presented considerable heterogeneity in the size of the effects. A majority (n = 27) of studies were assessed to be of low confidence related to methodological limitations, so the findings must be interpreted with caution. Tests for publication bias show that the effect sizes of social skills (p < 0.01) and social inclusion (p = 0.01) are all likely to be inflated by the existence of the publication bias.
Authors' Conclusions: The review's findings suggest that various interventions to improve the social inclusion of people with disabilities have a significant positive effect.
Interventions such as social and communication training and personal assistance led to significant improvement in the social behaviour and social skills of people with disabilities.
Studies targeting broad-based social inclusion showed a large and significant positive effect. A moderate effect was reported from interventions designed to improve relationships between people with disabilities and their families and communities.
However, the findings of this review must be interpreted cautiously, given the low confidence in study methods, severe heterogeneity and significant publication bias. The available evidence focused primarily on individual-level barriers such as interventions for improving social or communications skills of people with disabilities and not the systemic drivers of exclusions such as addressing societal barriers to inclusion, such as stigma reduction, and interventions to strengthen legislation, infrastructure, and institutions.
1 | PLAIN LANGUAGE SUMMARY 1.1 | Social inclusion interventions in low-and middle-income settings have a meaningful positive effect on people with disabilities There is promising evidence that interventions can improve the social skills and relationships of people with disabilities in low-and middleincome country (LMIC) settings. However, there is a lack of evidence on what works to improve social inclusion and community participation for this group.

| What is this review about?
There are approximately one billion people with disabilities. They are frequently excluded from social and political activities, which is a violation of their fundamental rights. A core reason for the exclusion exclusion, people with disabilities encounter various challenges in accessing services that others have long taken for granted, including healthcare, education, employment, and transportation (UN, 2018).
These difficulties are exacerbated in less advantaged communities and increase the risk of social exclusion and poverty (WHO, 2010).
These exclusions contradict the UN Convention on the Rights of Persons with Disabilities (UNCRPD), which supports the fulfilment of rights for persons with disabilities across diverse areas, including education, employment, and social participation.
Social exclusion impacts people with disabilities differently depending on their impairment type, gender, socioeconomic and cultural background, and other characteristics and contexts (WHO, 2010). For example, older people with disabilities are often discriminated against because of their age and disability, and older women may be particularly disenfranchised (UN Women, 2020).
People with certain impairment types may face exceptionally high levels of discrimination. For instance, people with albinism are often targeted in many parts of the world due to deep-rooted discriminatory beliefs, such as that their body parts can bring good fortune (Nebre, 2018). Societal stigma can result in people with psychosocial and intellectual disabilities being segregated, constrained in their homes, or institutionalised (Scior et al., 2015;p.6).
Social inclusion of people with disabilities is recognised as a fundamental right in the UNCRPD, including in 'participation in cultural life, recreation, leisure, and sport' (Article 30) and 'participation in political and public life (Article 29). Furthermore, other rights, for example, the right to education (Article 24), may not be realised without social inclusion. The Sustainability Development Goals (SDGs) are also relevant to this issue (UN, 2016), including SDG4 'Guaranteeing equal and accessible education by building inclusive learning environments and providing the needed assistance for persons with disabilities', and SDG 8 'Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all', SDG 10 'Emphasising the social, economic and political inclusion of persons with disabilities' and SDG 11 'Creating accessible cities and water resources, affordable, accessible and sustainable transport systems, providing universal access to safe, inclusive, accessible and green public spaces'. The SDGs may not be achieved if people with disabilities are excluded from equal participation in all aspects of life.
In addition to the value of the contributions people with disabilities make to society, there are costs associated with exclusion and gains associated with inclusion Polack, 2014).
Moreover, meaningful inclusion of people with disabilities, such as in the arts, sports, and community processes, can challenge stigmatising attitudes and norms and, in turn, reduce discrimination and social exclusion (Lundberg et al., 2011). In addition to enhancing health, well-being, self-esteem, dignity, and social connections, social inclusion of individuals with disabilities promotes economic opportunities and social connections in many ways (World Bank, 2020). The importance of inclusion in education cannot be overstated, as education is essential for skill development. Schools are crucial for developing social networks, peer relationships, friendships and influential linkages that may further lead to job opportunities or promote entrepreneurship (Hanushek & Wößmann, 2007). Similarly, employment facilitates social participation and improves human dignity and social cohesion. Providing education and livelihood inclusion for children with disabilities can also facilitate the achievement of other rights; for instance, schools and workplaces function as critical healthcare providers, including distributing food and drugs at school and accessing social assistance (UN, 2018).
Despite the benefits of social inclusion, WHO (2010) reports that people with disabilities suffer from widespread social exclusion, stigma, and discrimination in LMICs. For instance, studies conducted in India, Cameroon, and Guatemala show that adults with disabilities face more significant participation restrictions in interpersonal relationships and social, community, and civic with disabilities and a lack of opportunity for engagement in activities outside the home (Pinilla-Roncancio et al., 2020). A study conducted in refugee camps in Tanzania and conflict-affected Ukraine found that older people have a high degree of social isolation in all aspects of their livespolitical, economic, social, cultural, civil, and other-including denial of reasonable accommodation (Sheppard et al., 2018). It is therefore essential to develop and implement interventions that overcome the barriers limiting the social inclusion of people with disabilities, including physical barriers (e.g., inaccessible transport and buildings, community centres and sports facilities), as well as informational barriers (e.g., lack of sign-language interpreters at cultural events).

| The intervention
This review examines a broad range of interventions that may improve the social inclusion of people with disabilities. Social inclusion is considered per WHO's Community-Based Rehabilitation Guidelines (CBR) (WHO, 2010). The WHO has endorsed the concept of CBR as a way to improve the lives of persons with disabilities. One of the five pillars of CBR is 'social' (WHO, 2010). To classify interventions, we used five components of the 'social' pillar of the CBR matrix: personal assistance, relationship, marriage and family, culture and arts, recreation, leisure and sports, and justice. Table 1 lists specific interventions for each category (e.g., formal assistance and support, informal assistance and support). Therefore, the CBR will serve as a guiding framework for the intervention categories, as listed below, to realise the full inclusion and empowerment of persons with disabilities.
CBR's social pillar consists of five components: • Personal assistance: Personal assistance may be helpful as many people with disabilities have impairments and functional difficulties that make it difficult to carry out activities and tasks independently in their current environment. Personal assistance interventions include formal and informal personal assistance and support and personal assistance training (UNCRPD, 2017).
T A B L E 1 Intervention and sub-intervention categories.

Intervention category Intervention sub-category Description
Personal assistance Formal personal assistance and support (including trainings) Governmental, non-governmental organisations and the private sector offer a formal assistance programme. Sometimes, personal assistance can be funded by disability pensions, guardianship awards, or caregiver allowances .
Informal personal assistance and support (including training) Assistance from family members, friends, neighbours and/or volunteers .

Relationship, marriage and family
Networking and social support Providing people with disabilities with social support and networking opportunities includes linking them with support networks available in their community, such as disabled people's organisations (DPOs) and selfhelp groups .
Improving community attitude Efforts to promote positive images and role models of people with disabilities (e.g., through the media); and information on services available .
Community living Supporting people with disabilities to access their preferred living arrangements and helping people with disabilities who are homeless to find appropriate accommodation, preferably in the community.

Social and communication skill training
Training may focus on verbal and nonverbal behaviours common in social relationships, or on improving communication skills.

Violence prevention interventions
Interventions to prevent violence such as raising awareness, establishing links to local stakeholders for support, access to health care services, etc. .
Culture and arts Access and participation in cultural programme, arts, drama and theatres Provision of cultural materials, television programmes, films, theatre and other cultural activities, in accessible formats; accessibility of cultural performances or services, including theatres, museums, cinemas, libraries, tourism services, monuments and sites of national cultural importance (UNCRPD, 2007).

Access and participation in religious activities
Provision of religious and spiritual activities in accessible formats (e.g., making prayers, songs, chanting, and sermons accessible with signed translation, and making religious texts available in large print, audio and Braille), accessibility of places of worship and reasonable accommodations in religious practices (e.g., inclusive services) (UNCRPD, 2007).

Access and participation in sports events
Strategies that encourage people with disabilities to have access and provide opportunities to participate in mainstream sporting activities at all levels through inclusive sports event; have an opportunity to organise, develop and participate in disability-specific sporting and recreational activities through provision of support and links with OPDs for people with disabilities, assisting them to develop strategic, national and international partnerships and have access to adapted sports equipment  Access and participation in recreation and leisure Strategies that encourage people with disabilities to have access and provide opportunities to participate in mainstream sporting activities, recreation, tourism and leisure whether as a participant or observer  Justice Accessibility a of legal system and justice Support with access the legal system and justice, for instance through Examples include accessible built infrastructure of courts and police stations (e.g., such as ramps, etc.) Access to legal system and justice Suppor to access the systems, procedures, information, and locations used in the administration of justice (Lord & Stein, 2008) This includes activities such as legal awareness through OPDsDPOs and media, legal aid.

Assistive Technology and rehabilitation
Assistive Technology (AT) Assistive technology is an umbrella term covering the systems and services related to the delivery of assistive products and services. Assistive products maintain or improve an individual's functioning and independence, thereby promoting their well-being (e.g., wheelchairs, hearing aids).
(Continues) SARAN ET AL. • Justice: People with disabilities must have access to justice on an equal basis to ensure full enjoyment and respect of human rights.
Interventions include inheritance rights and provision of procedural and age-appropriate accommodations as witnesses in all legal proceedings at investigative and other stages. (UNCRPD, 2017).
We have added two additional categories to the CBR framework social pillar, which are relevant to promoting social inclusion: (1) Assistive Technologies (AT), Rehabilitation, and (2) Policies. We will consider interventions that specifically target people with disabilities, as well as mainstream programmes that are inclusive of people with disabilities.

| How the intervention might work
For people with disabilities to be able to participate fully in society, it is imperative to consider the barriers that prevent them from doing so. People with disabilities are not a homogenous group, and the reasons for exclusion will vary for women and men in different settings and people with different impairment types. It is important to note that barriers are often experienced at three levels: the individual, the community, and the system.

| Individual-level barriers
There are a variety of barriers to social inclusion at the individual level, including poor social and communication skills, a lack of assistive devices, a lack of personal assistance and support, or a lack of access to adapted equipment (e.g., for sport

Rehabilitation
Rehabilitation is a process intended to eliminate or at least minimiserestrictions on the activities of people with disabilities, permitting them to become more independent and enjoy the highest possible quality of life (Bailey;Angell, 2005). This will include physiotherapy, occupational therapy and psychological support activities as provision of mobility, hearing, visual devices, and therapies to use these devices.
Medical care Provision of medical services to ensure that people with disabilities can access services designed to identify, prevent, minimise and/or correct health conditions and impairments .

Policies and programmes
International legislations and policies International legislations and policies through which countries abolish discrimination against persons with disabilities and eliminate barriers towards the full enjoyment of their rights and their inclusion in society (UN, 2018) Social inclusion policies Inclusive policies on employment, educational and provision of housing and accommodation to people with disabilities.
a 'Accessibility', in this publication refers to a feature or quality of any physical or virtual environment, space, facility or service that is capable of accommodating the needs of people with disabilities to understand, get access to or interact with legal system. Accessibility also refers to technical standards that are mandated nationally or internationally for the design and construction of a physical or virtual environment, space, facility and service who live in segregated or institutionalised housing or are constrained within their homes.

| Community-level barriers
Among the community's barriers are physical barriers (e.g., inaccessible transport and buildings such as community centres and sports facilities) and informational barriers (e.g., non-availability of sign-language interpreters at cultural events), negative attitudes and beliefs among the community towards the participation of people with disabilities, as well as a lack of advocacy and volunteer groups (Organizations of People with Disabilities [OPDs]).

| System-level barriers
Among the system-level barriers are inadequate resource allocation to facilitate social inclusion for people with disabilities (e.g., personal assistance, supported independent living), the lack of legislation and policies that affirm the rights of people with disabilities to social inclusion, and the lack of inclusion of people with disabilities in decision-making processes. Existing laws and regulations that require accessible programmes and activities are not recognised or enforced.
To improve the social inclusion and outcomes of people with disabilities, addressing the barriers they encounter is necessary. In other words, they must operate at the level of the individual (e.g., personal assistance training and support), community (e.g., access to buildings such as community centres and recreation centres), and system (e.g., improving policy and legislation) ( Figure 1).

| Why it is important to do this review
Social inclusion of people with disabilities is recognised as a fundamental right in the UNCRPD, including in 'participation in cultural life, recreation, leisure, and sport' (article 30) and in participation in political and public life (Article 29). Furthermore, without social inclusion other rights (e.g., right to education) may not be realised.
Social inclusion is also fundamental to implementing the 2030 Agenda; as long as people with disabilities are excluded from equal participation in all aspects of life, the SDGs arguably cannot be achieved. The wider society also benefits from the valuable contributions that people with disabilities make. Promoting social inclusion for people with disabilities, will also mean that 'People with disabilities have meaningful social roles and responsibilities in their families and communities, and are treated as equal members of society' .
Several relevant systematic reviews and protocols exist that are relevant to the topic, but none which addresses the stated objectives of this review. Two reviews focussed on components of social inclusion. Almerie et al. (2015) conducted a review of social skills programmes for people with schizophrenia and identified 13 randomised controlled trials (RCTs) (Almerie et al., 2015). They concluded that social skills training may be effective at improving the social skills of people with schizophrenia, but that the data is limited and of very low quality. A systematic review of the effectiveness of interventions to prevent and respond to violence against persons with disabilities (Mikton et al., 2014 It is important to note that the underlying assumption of some individual-focused social inclusion interventions is not unproblematic: these programmes assume that you can equip individuals to improve their own social inclusion through for instance, improved mobility or social capital. This assumption may seem to elide the reality that large structural forces often drive social exclusion. However, they are an important avenue through which interventionists currently try to improve social inclusion outcomes, and so have been included here. randomised studies with a control group, including controlled beforeand-after (CBA). We included studies using the following study designs: (a) participants are randomly assigned (using a process of random allocation, such as a random number generation), (b) a quasi-random method of assignment has been used, (c) participants are non-randomly assigned but matched on pre-tests and/or relevant demographic characteristics (using observables or propensity scores) and/or according to a cut-off on an ordinal or continuous variable (regression discontinuity design), (d) participants are non-randomly assigned, but statistical methods have been used to control for differences between groups (e.g., using multiple regression analysis or instrumental variables' regression), (e) the design attempts to detect whether the intervention has had an effect more significant than any underlying trend over time, using observations at multiple time points before and after the intervention (interrupted time-series design), (f) participants receiving an intervention are compared with a similar group from the past who did not (i.e., a historically controlled study), or (g) observations are made on a group of individuals before and after an intervention, but with no control group (single-group beforeand-after study).

| Types of participants
The target populations are people with disabilities living in LMICs.
Population subgroups of interest include: women, vulnerable children

| Types of outcome measures
Eligible outcomes will relate to the social inclusion pillar of the CBR matrix. The outcome of interest include outcomes listed in Table 2.
Duration of follow-up. Any duration of follow-up was included.
Types of settings. All settings were eligible, provided that the study is situated within a LMIC, as defined by the World Bank, 2018 (https:// datahelpdesk.worldbank.org/knowledgebase/articles/906519-worldbank-country-and-lending-groups).

| Search methods for identification of studies
The search for this systematic review is based on the searches performed for the evidence and gap map on interventions for people with disabilities in LMICs (Saran et al., 2020). The EGM presents studies on the effectiveness of interventions for people with disabilities in LMICs. We updated the database search in February 2020 and screened the references to identify additional studies (Supporting Information: Appendix 1). To identify any relevant articles that may have been missed during the EGM processes, we ran the searches with search terms specific to social inclusion review using Open Alex in EPPI reviewer (Thomas & Stansfield, 2018).

| Electronic searches
The authors searched the following electronic databases.
Search strategies were tailored for each of the databases.

| Searching other resources
To maximise the coverage of unpublished and grey literature and minimise publication bias, we searched the following organisation's websites and databases using keyword searches.

• WHO
• Disability Programme of the UN Economic and Social Commission for Asia and the Pacific (UNSCAP) • United States Agency for International Development (USAID) • Dissertation Abstracts, Conference Proceedings and Open Grey.
• Humanity and Inclusion (HI) http://www.hi-us.org/publications • CBM https://www.cbm.org/Publications-252011.php • Plan international https://plan-international.org/publications We also ran the searches with search terms specific to social inclusion review using Open Alex in EPPI reviewer 4.

| Description of methods used in primary research
The titles and abstracts of all documents included were screened by two independent reviewers using EPPI Reviewer 4. Two reviewers evaluated the full texts of studies that met or appeared to meet the inclusion criteria. If there were any disagreements, they were T A B L E 2 Outcome and outcome sub-categories.

Skills for social inclusion Social and communication skills
Social skills as learned verbal and non-verbal behaviour performed within a specific social context of an aggressiveness-shyness continuum, and view adjustment in relation to an individual's social perceptual accuracy (i.e., the ability to understand subtle nuances and define critical elements in social environment) (Kratochwill & French, 1984). Communication skills is the ability to transfer information. It may be vocally (using voice), written (using printed or digital media such as books, magazines, websites or emails), visually (using logos, maps, charts or graphs) or non-verbally (using body language, gestures and the tone and pitch of voice). This includes availability and use of communication aids and speech and reading devices Social behaviour Social behaviour can be defined as all behaviour that influences, or is influenced by, other members of the same species. The term thus covers all behaviour that tends to bring individuals together as well as all forms of aggressive behaviour (Grant, 1963). This includes conduct problems, peer problems, pro-social behaviours.
Broad based social inclusion and participation measure

Social inclusion and community participation
Social inclusion is defined as the process of improving the terms of participation in society, particularly for people who are disadvantaged, through enhancing opportunities, access to resources, voice and respect for rights. (UN, 2010). These will include measures such as people with disabilities spending more time out of the house, and travelling further away from the house and a greater number and depth of social interactions. People with disabilities have access, accessibility and opportunities to participate in community activities such as leisure activities, such as hobbies, arts, and sports, political and civic activities or organisations and productive activities, like employment or education; consumption, or access to goods and services; religious and cultural activities and groups.
Access to justice People with disabilities get access to or interact with legal system

Relationships Interpersonal and Family relationship
People with disabilities have strong relationships with family members, staff, friends, acquaintances, and intimate partners (Clarkson et al., 2009) and other people with disabilities, and feeling a sense of belonging to a network when they have different people fulfilling different needs (McVilly et al., 2006). This also includes aspects of participation in household, behaviour of the family towards people with disabilities Peer and community relationships People with disabilities have meaningful relationships, marry and have children.

| Criteria for determination of independent findings
Before initiating the synthesis (detailed below), we ensured that all articles reporting on the same study were appropriately linked, as several articles could be published using data from the same sample.
Furthermore, studies can report multiple outcomes, in which case we selected the most relevant measure for analysis using the following decision rules: Outcomes measured via validated formal scales are more relevant than those measured using a single-item question. We only extracted data on the intervention and control groups eligible for this review for studies with multiple intervention arms. Should a multiarm study report multiple relevant intervention arms, the findings from the different arms were reported and analysed separately.

| Selection of studies
Two review authors independently screened the articles for title and abstract and full-text with a third-party arbiter in case of disagreement.

| Data extraction and management
Two review authors independently extracted the necessary data from each study report. Data and information were extracted on available characteristics of participants, intervention characteristics and control conditions, research design, sample size, risk of bias and outcomes, and results. Extracted data were stored electronically. The coding sheet for this review is included in Supporting Information: Appendix 2.

| Assessment of risk of bias in included studies
Two review authors independently assessed the risk of bias for each included study. We resolved any disagreements by discussion or by involving a third review author. We evaluated the risk of bias according to the following domains. Confidence in study findings was rated high, medium, or low for each criterion, applying the standards as shown in Supporting Information: Annex 3. Overall confidence in study findings was determined to be the lowest rating across the criteria-the weakest link in the chain principle.
• Study design

| Unit of analysis issues
The unit of analysis of interest to the present review was individual people with disabilities, their caregivers, carers, or those working with them. If a study had more than two intervention arms, we included only intervention and control groups that met the eligibility criteria.
Where multi-arm studies were included, we ensured not to doublecount participants and separately reported eligible interventions and their respective outcomes.

| Dealing with missing data
Attrition was calculated for each study, and an evaluation was conducted to assess the overall quality of the study. No included study was eliminated from the analysis due to missing data. the studies using an extraction form piloted before use. After coding each study and extracting/calculating each effect size, the metafor package in R was used to conduct random effects inverse variance meta-analyses with 95% CIs. The magnitudes of the mean effect size (SMD) were then interpreted according to Cohen's (1988) convention:

Outcome characteristics
Most outcomes fell into the category of improving social skills, with 13 studies examining social and communication skills [Abazari et al., 2017;Esmaili et al., 2019;Golzari et al., 2015;Govindaraj et al., 2018;Kalgotra & Warwal, 2017;Karanth et al., 2010;Lal, 2010;Lee et al., 2019;Liang et al., 2022;Nair et al., 2014;Pajareya & Nopmaneejumruslers, 2011;Rahman et al., 2016;Shin et al., 2009] and 12 social behaviour [Abazari et al., 2017;Esmaili et Yildiz et al., 2004;and Zuurmond et al., 2018). We found only one study assessing violence and abuse (Devries et al., 2018) and peer and community relationship (Hanlon et al., 2020). No studies were identified on access to justice. common reasons for exclusion were that the study was not an impact evaluation, presented a protocol for which there were no associated results, focused on an ineligible population, had a social inclusion intervention but no social inclusion outcomes, provided only qualitative data, and-in one case-otherwise relevant findings were not disaggregated for people with disabilities.

| Risk of bias in included studies
Overall there is low confidence in the study findings for 27 of the 37 studies (Table 4). Five studies [Juneja et al., 2012;Karaman et al., 2020;Manohar et al., 2019;McConachie et al., 2000;Rahman et al., 2016] scored medium using our assessment tool.
We found five studies [Amaresha et al., 2018;Esmaili et al., 2019;Pajareya & Nopmaneejumruslers, 2011;Rami et al., 2018;Yildiz et al., 2004] that scored high confidence in the findings. There is diversity within low ratings as we employed the weakest link in the chain principle to assess confidence in study findings (Supporting Information: Appendix 3). However, the findings of a study receiving a low rating on a single item (e.g., for reporting of attrition) should not be treated in the same manner as those derived from a study rating low on multiple items. The latter approach allows for valuable learning not to be overlooked due to an overall 'low' confidence in study findings score, in studies which had many areas of strength.

Study design
Nineteen studies were rated 'low' on study design as many used before and after designs. Eighteen studies were rated high in our assessment of confidence in study findings based on design, as they were randomised controlled trials.

Masking
Of the 18 randomised controlled trials, only 7 studies were rated as high and were masked for data collection (where feasible) and masking for analysis and 5 studies were rated medium they were masked for analysis. For six studies masking was not mentioned and was rated as low in our assessment of confidence in study findings.

Losses to follow-up presented and acceptable
The issue of incomplete outcome data was not addressed adequately in six studies putting them at high risk of attrition bias due to significant loss to follow-up from both intervention and control groups. Studies that were at low risk addressed incomplete outcome data adequately in 27 studies and 4 were assessed to be of mediumrisk of bias.

Disability/impairment measure definition and reliability
One of the areas which received relatively good ratings across studies was the use of disability/impairment measures or definitions which were consistently clear and reliable. Only four studies received a rating of 'low' and one a 'medium' rating. In all the remaining studies, rigorous and replicable criteria were used, and high ratings were given. Li et al. (2018) included individuals with psychosocial disabilities (schizophrenia) and the Brief Psychiatric Rating Scale was used to assess the participants' psychiatric status. In the study Azari et al. (2019); a detailed measure of impairment, the Washington Group questionnaire was used.

Outcome measures definition and reliability
Outcome measures were largely well-defined, perhaps reflective of the tendency of the studies to be outcome-driven interventions, and so primarily concerned with operationalizing and then acting upon, a particular dimension of social inclusion. All but one study received high ratings on this item.

Baseline balance
As with masking, baseline balance was only relevant for the 18 studies, including the randomised controlled trial. Randomised controlled trial studies reported acceptable baseline balance and were coded as high on this item for all but one study.

| Synthesis of results
We conducted meta-analysis with 37 studies, categorised into three outcome categories according to the pathway developed earlier in the study (Figure 1). Skills for social inclusion, relationships, and broad-based social inclusion were the outcomes of interest. To conduct the meta-analysis, we used independent estimates, I2 statistics, and their corresponding p-values to determine the differences between the effect sizes across the different outcome types. For each outcome of interest, effect sizes are calculated using SMDs, which indicate changes in scores between the control and intervention groups. SMD scores are interpreted as the number of standard deviation changes in the outcome. Table 5, it is shown that high heterogeneity is evident in all three areas: social skills (I = 94%), social behaviour (I = 90%), and social inclusion (I = 93%). A relatively small number of studies were used in the analysis for personal assistance (n = 7), social inclusion (n = 9) and interpersonal relationships (n = 6). Only one study was identified on violence and peer relationships.  (SMD = 0.87, 95% CI = 0.57 to 1.16) (Figure 4). Examination of the I 2 suggested high levels of heterogeneity (I 2 = 93%, p < 0.001). The influence of the intervention is also apparent for sub-categories of this outcome, such as social behaviour (SMD = 0.94, CI = 0.50 to 1.38, k = 13, I 2 = 90%, p < 0.001) and social skills (SMD = 0.80, CI = 0.37 to 1.23, k = 13, I 2 = 94%, p < 0.001). The heterogeneity measure is high across most outcomes, as studies are dispersed in methods, study design and quality.

Relationship
As shown in Figure 6,  Relationships. The results for the subgroup analysis by type of impairment can be found in (Figure 8). For this analysis, we pooled the three outcome sub-categories: interpersonal/family relationship, peer/community relationship and violence/abuse into one outcome measure due to a lack of data for the violence and community relationship (any subgroup analysis of size one would be meaningless  In the studies of personal assistance, the test shows no systematic difference between the groups (χ 2 = 2.46, df = 1, p= 0.29) even though the differences in effect sizes are considerable. The smallest, but also the most persistent, is the effect for people with

| Publication bias
We examined publication bias by the funnel plot ( Figure 10) and then confirmed by Eggar's test ( Egger's test 3.71 (t = 3.14, p= 0.01). In all the cases, small studies with higher standard errors systematically report higher values than studies with lower standard errors, which are seen as more precise.
Even though these are unlikely to reverse the relatively robust study results, we should consider limitations when interpreting the effect sizes.

| DISCUSSION
This review examines the effectiveness of interventions aimed at improving social inclusion outcomes (acquisition of skills for social inclusion, broad-based social inclusion, and improved relationships) for people with disabilities in LMIC. We searched academic and online databases, carried out citation tracking of included studies and contacted experts to ensure our search was as comprehensive as possible. We also ran the searches with search terms specific to social inclusion review using Open Alex in EPPI reviewer (Thomas & Stansfield, 2018).

| Summary of main results
We interpersonal relationships (k = 6), violence (k = 1) and peer relationships (k = 1). Evidence also suggested the presence of publication bias, particularly related to social skills (p < 0.01) and social inclusion (p = 0.01), are all likely to be inflated by the existence of the publication bias. Also, given the low confidence (n = 27) in study findings related to methodological limitations, the findings must be interpreted with caution.
Overall, the review's findings suggest that the Interventions such An important gap is the lack of studies addressing community and societal-level barriers as outcomes or interventions, so that interventions were generally individual targeted. Moreover, only two studies were identified that addressed stigma reduction, albeit these showed improved attitudes to the person with disabilities due to the intervention. This gap is a critical omission, as stigmatising attitudes and norms are major barriers to the social inclusion of people with disabilities and their empowerment.
Disability is a highly heterogeneous category, including people with a broad range of impairments who will face different challenges and facilitators to social inclusion and empowerment. Most studies focused on people with intellectual disabilities and psychosocial impairments.
Hence, it was impossible to compare the intervention's effectiveness for people with different or multiple impairments.
People with disabilities experience exclusion and disempowerment in diverse ways depending on their impairment type, gender, ethnicity, and other characteristics and contexts. The studies failed to disaggregate by gender, limiting our ability to discern whether interventions were equally effective for both genders or to explore the intersectionality between disability and other characteristics associated with discrimination, such as age and ethnicity. Studies are needed that assess interventions for a broader range of impairment types, for both genders, in humanitarian contexts and allow disaggregation of effects.

| Quality of the evidence
The strength of the review is that we have included studies that used randomised or other rigorous quasi-experimental study designs to answer our review questions. About 48% of the included studies used an RCT design with randomly allocated treatments to individuals or clusters. Of these, 27% (n = 5) were assessed to be of highconfidence by the confidence in the study findings tool. Overall, 72% of the studies were assessed to be of low quality and have methodological limitations. The quality of the included studies is therefore generally low For example, losses to follow-up and other vital dimensions of study rigour were frequently either poorly recorded or poorly reported.

| Agreements and disagreements with other studies or reviews
Evidence within the existing systematic reviews is consistent with our finding that interventions were effective at improving social inclusion of people with disabilities For instance, Velema et al. (2008)  The evidence base on stigma reduction interventions for people with disabilities is weak. There is an urgent need for a holistic research approach to stigma reduction aimed at changing behaviour rather than raising awareness.

| Implications for research
The LGBTQ+ community or whether interventions were cost-effective.
Hence, studies undertaken should consistently consider a broad range of characteristics and aspects of identity (e.g., gender, ethnicity, and intersectionality), which may influence outcomes.

ACKNOWLEDGEMENTS
We would like to acknowledge UK Department of International • Systematic review method and statistical analysis expertise: All team members have previous experience in systematic review methodology, including search, data collection, statistical analysis, theory-based synthesis, which mean they are proficient in carrying out the various processes in a systematic review, such as search, eligibility screening, quality assessment and coding. Furthermore, all three authors have experience in statistical analysis of data generated through a systematic review.
• Information retrieval expertise: All authors have previous experience in developing search strategies.

DECLARATIONS OF INTEREST
The authors have no interests to declare.